| Dental Item Code | Dental Service | Recommended Fee | SmileCare Budget Fee |
| Diagnostic | |||
| 011 | Initial Check-Up |
$120
|
$54
|
| 012 | Periodic Check-Up |
$90
|
$50
|
| 013 | Specific Examination |
$100
|
$54
|
| 014 | Consultation |
$110
|
$60
|
| 022 | X-ray – Per Film | $70 | $38 |
| 037 | X-ray – Panoramic (OPG) | $180 | $99 |
| Preventive | |||
| 111 | Removal of plaque | $110 | $60 |
| 114 | Scale and Clean | $240 | $109 |
| 115 | Scale and Clean (additional visit) | $240 | $109 |
| 121 | Fluoride Application | $60 | $38 |
| 161 | Fissure Sealing – Per Tooth | $100 | $55 |
| Oral Surgery | |||
| 311 | Extraction | $385 | $198 |
| 314 | Complex Extraction | $480 | $249 |
| 324 | Surgical Extraction | $1,100 | $550 |
| Root Canal Treatment excluding X-rays |
|||
| 411 | Direct Pulp Capping | $190 | $40 |
| 419 | Emergency Relief of Root Canal Pain | $520 | $190 |
| 455 | Additional visit for dressing of Root Canal System – Per Tooth | $207 | $99 |
| 415, 417 | Root Therapy (1 Canal) | $1,120 | $636 |
| 415, 416, 417, 418 | Root Therapy (2 Canals) | $1,680 | $825 |
| 415, 416 x 2, 417, 418 x 2 | Root Therapy (3 Canals) | $2,240 | $1,014 |
| Fillings – Amalgam (silver) and Resin (white) | |||
| 511, 521 or 531 | 1 Surfaces | $290 | $159 |
| 512, 522 or 532 | 2 Surfaces | $360 | $189 |
| 513, 523 or 533 | 3 Surfaces | $430 | $229 |
| 575 | Retention Screw/Pin | $80 | $45 |
| 577 | Cusp Capping – Per Cusp | $80 | $45 |
| 578 | Restoration of Corner | $80 | $45 |
| 582 | Composite Resin Veneer | $508 | $450 |
| 583 | Porcelain Veneer | $2,200 | $1,200 |
| Crowns & Bridges (Lab Fees Included) | |||
| 615 | Porcelain Crown with Metal Frame | $1,940 | $990 |
| 627 | Core for Crown | $440 | $245 |
| 643 | Bridge (per tooth) | $1,614 | $990 |
| 651 | Recement Crown or Veneer | $220 | $120 |
| 688, 627, 615 | Single Stage Dental Implant | $4500-5000 | $2750-3850 |
| Prosthodontics | |||
| 721 | Partial Denture Acrylic Base | $1,500 | $825 |
| 727, 728 | Partial Denture with Cast Metal Framework | $2,440 | $1,350 |
| 733 | Per Tooth on Partial Denture | $60 | $35 |
| 768 | Add Tooth to Partial Denture | $480 | $295 |
| Snap-On Smile | |||
| Snap-On Smile (per arch) | $2600 | $2400 | |
| General | |||
| 927 | ZOOM Whitening Pens | $85.00 for double pack which can be posted out for another $6.50 just call to pay then we can post that day | |
| 965 | Occlusal Splint | $771 | $395 |
Im 24 and 2 of my wisdom teeth still come up and down, when ever they want. But ive noticed that now they are black and hurt even more than normal. How much would it cost for them to be taken out? Including the concolt?